Healthcare Provider Details

I. General information

NPI: 1356013684
Provider Name (Legal Business Name): BRADLEY BIBB, MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 HIGHWAY 62 412
ASH FLAT AR
72513-9594
US

IV. Provider business mailing address

4196 HIGHWAY 62 412 STE A
HARDY AR
72542-8002
US

V. Phone/Fax

Practice location:
  • Phone: 870-856-1202
  • Fax: 870-856-2107
Mailing address:
  • Phone: 870-856-1202
  • Fax: 870-856-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: SUSAN RENE NEELY
Title or Position: CRED SUPER
Credential: RN
Phone: 870-856-1202